Endocrine emergencies JCCC EMT (EMS 132)

glucose 

a carbohydrate that feeds the body

glucogon

a type of hormone from the pancreas that “knocks on the door” of the liver and takes its glycogen and turns it back into glucose

secreted from pancreas when BG falls below 70ish

converts non-carb things into glucose

prevents body from storing glucose as glycogen

glycogen

insulin takes extra glucose to the liver and turns it into glycogen to be stored for later

glycogen is not stored well in…

certain diabetics

pediatrics

starved people

how does glucose get into the brain and cells

the brain drinks it on its own

cells need insulin

why is there more urine in hypergl.

the kidneys filter sugar out because it cant absorb in the cells. the movement of a large glucose molecule attracts water with it causing excess urination and dehydration.

insulin

the key that lets glucose into the cells

hormone released when we eat

causes liver to store extra glucose as glycogen

when there is no glucose in the cell, the cell…

breaks down fat to make energy

normal bgl?

after eating?

70-120

120-140 after 1 hour

between meals when people ignore hunger/sleep…

glucagon is secreted to make more glucose and normalize bgl

if a diabetic throws up after eating…

thats bad because they took their insulin and now there is no food. So their bgl is gonna tank

epinephrine in relation to diabetes 

released as another compensation effort when bgl are really low.

promotes release of glucagon

stops secretion of insulin

promotes conversion of other substances into glucagon

the two main types of diabetes and their second names

type 1 (insulin dependent diabetes mellitus)- no insulin- must take insulin to survive

type 2 (non-insulin dependent diabetes mellitus)- insulin resistant- can be controlled. by exercise, diet, and oral meds

diabetes insipidus

large amounts of dilute urine (can be 20 liters per day) and increased thirst. Pretty rare

the three P’s of diabetes 

polyuria- pee

polydipsia- thirst

polyphagia- hunger

usually type 1 but can be both

expansion ?s

more thirsty

pee more

more hunger?

take insulin, pills, both?

did they eat a normal meal

any unusual exertion

onset sudden or gradual

any other causes for AMS

type of diabetes?

recent bgl readings

recent infection, illness, disease, pregnancy

common prescription meds for diabetes

type 1

insulin- humulin

short acting- Humalog

long acting- lantus

type 2 (oral)

glucotrol, glucophage, diabanse

• causes release of bodies insulin and may help restore proper response to it.

the 2 types of insulin

short acting (emergency) and long acting

insulin shock

(hypoglycemia)

causes: didnt eat, to much exercise, OD on insulin

bgl of <60 with s/s

OR

<50 w/o s/s

s/s of hypo

many are like shock

cool clammy, pale, sweaty, tachycardia, tremors, AMS with rapid onset, weak, dizzy, headache, seizures, “drunklike”, normal BP, blurred vision

diabetic ketoacidosis (DKA) what it is and s/s

bg greater than 300

cells begin to burn fat because they dont have energy. BGL keeps rising. The burned fat makes ketones which lowers PH (acid) in the blood. The body eliminates the ketones with kussmaul’s breathing

kussmaul’s

thirsty, dehydrated

fruity breath

onset: 12-48 hrs

AMS or U

warm dry skin

tachycardia- can be weak

normal BP or positive tilt test (drops)

abdominal pain

N/V

could eventually go into a coma and die

HHNS- stand for? what is it? s/s?

Hyperglycemic hyperosmolar Nonketotic syndrome

Blood sugar sky rockets because there are no ketones in the blood (as a result of just enough insulin). The ketones in DKA make the body energy so that the bgl stops raising, but in HHNS that doe not happen.

hyperosmolar means blood is extremely concentrated

usually type 2

s/s

onset 3-7 days

no fruity breath

warm dry skin

normal respirations

dehydration- more significant w/o acidosis

AMS

tachycardia- weak

3 P’s

low bp and + tilt test

bgl 600-1200

hypothalamus

brain region controlling the pituitary gland

pituitary gland

secretes many hormones that can control other glands

thyroid

affects metabolism, growth/development

parathyroids

regulates level of calcium in blood

adrenal glands

fight or flight response

2 things can cause endocrine emergency (not diabetes)

preexisting disorder

precipitating factor interferes with management of the disorder

hyperthyroidism and graves

Graves is when antibodies stimulate the thyroid and also inflames the tissue behind eyes and skin around shins becomes thicker (pretibial myxedema)

it makes epi and norepi more effective (catecholamines)

Fatigue, muscle weakness

Sweating

Agitation, insomnia

Weight loss

Goiter- overactive thyroid probably from graves

Heat intolerance

Palpitations/new a-fib,

Diarrhea

Higher BGL

Exophthalmos [abnormal protrusion of the eyeball(s)]- also from graves.

BMR

Basal metabolic rate- the rate that the body uses energy for normal body functions while at rest

thyroid storm- how? s/s? whats happening?

2 conditions met: 

• past hyperthyroidism

• precipitating factor- trauma, illness, OD on hypothyroid drugs or stopping hyperthyroid drugs

Basically- since hyperthyroidism makes epi and norepi more effective, when the body has a trauma event, the release of stress hormones push it over the edge

sympathetic hyperactivity

• hyperthermia (fever of 106)

• HTN then shock- bc of heart failure

• severe tachycardia and tachydysrthmias 

• agitation, paranoia, delirium, unresp.

• flushed wet skin

• abd pain, diarrhea, vomit

• high bgl

What does the thyroid do

Makes t3 and t4 which control how you spend/make energy

Also makes calcitonin which lowers blood calcium levels

Parathyroid hormone

Raises blood calcium levels

catecholimines

epi, dopamine, and nor epi

hyperthyroidism makes them more effective

hypothyroidism s/s and what it is

Hashimoto’s Thyroiditis

Iodine deficiency

decreased BMR

Hashimoto’s Thyroiditis- when an autoimmune disease causes the immune system to attack thyroid tissue. May cause goiter bc of inflammation and also the pituitary gland wants more thyroid hormones so releases more TSH.

Iodine deficiency- the thyroid needs iodine to make t3 and t4. Without it, the thyroid keeps getting stimulated (goiter forms) but no thyroid hormones are made.

cool dry skin

feel cold

fatique

bradycardia

Constipation

hypotension

slow shallow RR

Lower BGL

weakness

hoarse voice certain chemicals attract and hold water around larynx

Myxedema coma-what,  how, why, s/s

when hypothyroidism is combined with precipitating factors

The stressor basically activates the fight or flight but the body is out of energy and begins to actually fail

s/s

•Hypothermia – as low as 75°F/24°C!

•Respiratory depression

•Hypotension

•Extreme bradycardia

Sometimes hypoglycemia

•AMS to unresponsive – hallucinations – seizures - deep coma

Aldosterone

tells kidneys to retain sodium , maintain BP, and excrete potassium

ADH

Make distal tubules and collecting ducts of kidneys more permeable to water so we retain it

cortisol

A long term stress hormone that supports blood sugar, blood pressure and energy for long periods of time

• tells liver to make more glucose

• Breaks down fat and proteins for more energy

• Stops growth and repair- just survive

• Makes catecholamines more effective

• Depresses immune system- doesn’t wanna damage tissues

Addison’s disease- what, how, s/s

Hyposecretion of adrenal gland (could be secondary to pituitary gland dysfunction)

1.) Aldosterone lack- causes low water retention and high potassium. Low BP

2.) Cortisol lack- low BGL and response to epi and nor epi

•Subjected to new emotional or physiological stressors such as alcohol intoxication, surgery, AMI, trauma, infection, severe illness, etc.

•Managed in non-stressed situations pretty well unless overwhelmed by new or bigger stressors. 

•Suddenly stops taking steroid medications –these medications depress the adrenal cortex’s activity.

Signs & Symptoms:

•Fine wrinkled skin

•Increased skin pigmentation- the hormone telling adrenal cortex to release also releases more melanin

•Weight loss- bc of lack of glucose and loss of appetite and less fluids

•Weakness/fatigue

•Nausea, vomiting, diarrhea, abd pain, loss of appetite - Electrolyte imbalance, Low perfusion to GI tract, Stress hormone deficiency

•Hypoglycemia

•Dehydration- sodium waster in urine

•Hypotension/ shock- low aldosterone (sodium) and cortisol causes poor response to catecholamines

•Decreasing LOC

•Fever (if infection is precipitating factor)

cushings syndrome- what, why, s/s

Increase in cortisol released from adrenal glands

•Usually caused by tumors of the pituitary gland or medications (steroids)

•May lead to Cushing’s disease

Signs & Symtoms: 

•Personality changes

•Weight gain with thin extremities

•Water retention

•Buffalo hump- bump on neck

•Thin skin

•Petechia- tiny bruises

•GI issues

•Hyperglycemia

diabetes complications

wounds dont heal, numbness in hands and feet, 

diabetic physical exam

look for insulin pump

assess for sunken eyes

signs of seizure

breath odors

abdominal pain

what do you do with the insulin pump ifthey are hypo

if you are giving interventions (glucose or glucagon) then leave it on

no interventions- take it off/diasble it

 likely causes of hyperglycemia

3 i’s

Insulin- medication changes for insulin or oral diabetes medications, medication

non-compliance, or malfunction of insulin pump

Ischemia- hyperglycemia can be an indication of physiologic stress and may

suggest significant underlying pathology such as septic shock or ACS

Infection: underlying infections can cause abnormalities in glucose control